Tricuspid regurgitation differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fatimo Biobaku M.B.B.S [2]

Overview

The blowing holosystolic murmur of tricuspid regurgitation must be distinguished from the murmur of mitral regurgitation and a ventricular septal defect.

Differentiating Tricuspid regurgitation from other Diseases

Tricuspid Regurgitation	Mitral Regurgitation	VSD	Constrictive Pericarditis
Can be best heard over the fourth intercostal area at left sternal border. The intensity can be accentuated following inspiration (Carvallo's sign) due to increased regurgitant flow in right ventricular volume. Tricuspid regurgitation is most often secondary to pulmonary hypertension. Primary tricuspid regurgitation is less common and can be due to bacterial endocarditis following IV drug use, Ebstein's anomaly, carcinoid disease, or prior right ventricular infarction.	The murmur in mitral regurgitation is high pitched and best heard at the apex with diaphragm of the stethoscope with patient in the lateral decubitus position. Left ventricular function can be assessed by determining the apical impulse. A normal or hyperdynamic apical impulse suggests good ejection fraction and primary mitral regurgitation. A displaced and sustained apical impulse suggests decreased ejection fraction and chronic and severe mitral regurgitation.	The holosystolic murmur can be best heard over the left third and fourth intercostal spaces and along the sternal border. When the shunt becomes reversed (Eisenmenger's syndrome), the murmur may be absent and S2 can become markedly accentuated and single.	Severe TR has been documented to mimic some hemodynamic findings in constrictive pericarditis, with right heart catheterization demonstrating a constrictive physiology. Echocardiography, CT thorax, and cardiac MRI are useful for ruling out pericardial pathology.

Tricuspid Regurgitation	Mitral Regurgitation	VSD	Constrictive Pericarditis
Can be best heard over the fourth intercostal area at left sternal border. The intensity can be accentuated following inspiration (Carvallo's sign) due to increased regurgitant flow in right ventricular volume. Tricuspid regurgitation is most often secondary to pulmonary hypertension. Primary tricuspid regurgitation is less common and can be due to bacterial endocarditis following IV drug use, Ebstein's anomaly, carcinoid disease, or prior right ventricular infarction.	The murmur in mitral regurgitation is high pitched and best heard at the apex with diaphragm of the stethoscope with patient in the lateral decubitus position. Left ventricular function can be assessed by determining the apical impulse. A normal or hyperdynamic apical impulse suggests good ejection fraction and primary mitral regurgitation. A displaced and sustained apical impulse suggests decreased ejection fraction and chronic and severe mitral regurgitation.	The holosystolic murmur can be best heard over the left third and fourth intercostal spaces and along the sternal border. When the shunt becomes reversed (Eisenmenger's syndrome), the murmur may be absent and S2 can become markedly accentuated and single.	Severe TR has been documented to mimic some hemodynamic findings in constrictive pericarditis, with right heart catheterization demonstrating a constrictive physiology. Echocardiography, CT thorax, and cardiac MRI are useful for ruling out pericardial pathology.